Local Rule. Departmental Occupational Health & Safety Management Arrangements

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1 Local Rule Departmental Occupational Health & Safety Management Arrangements

2 Local Rule: Departmental Occupational Health and Safety Management Arrangements CONTENTS 1. Introduction University Occupational Health and Safety Policy Occupational Health and Safety Management System Aim and Scope Terminology 4 2. Key Role of Head of Department 4 Page 3. Organising for Effective Management Understanding the Department s Undertaking Understanding the Department s Hazard Profile Allocating Health and Safety Functions Ensuring Competence and Supervision Ensuring Communication 6 4. Planning and Implementing Arrangements University-wide Arrangements Preparing Departmental Occupational Health and Safety Arrangements Developing a Programme of Risk Assessments & Safe Systems of Work 8 5. Measuring Performance Reports of Accidents, Dangerous Occurrences and Cases of Occupational Ill Health Safety Inspections Annual Health and Safety Report 9 6. Reviewing Performance 9 7. References and further reading 9 For accompanying Appendices, see separate document: Appendices for Local Rule: Departmental Occupational Health and Safety Management Arrangements, which comprises: Appendix 1 Appendix 2 Model Departmental Occupational Health & Safety Arrangements Model Departmental Occupational Health & Safety Roles Issue date: January

3 1. Introduction 1.1 University Occupational Health and Safety Policy The University s Occupational Health and Safety Policy (OHS Policy) forms a key part of the University s Occupational Health and Safety Management System and represents its commitment to, and plan of action for, managing health and safety requirements. The OHS Policy documentation comprises the following inter-related levels: Level 1 The Occupational Health and Safety Policy Statement; an outline of the Occupational Health and Safety Management System adopted; the Leadership, Responsibilities and Organisation for implementing and communicating the OHS Policy; an outline of Occupational Health and Safety Arrangements that exist for a range of University work activities and issues. Level 2 Detailed Occupational Health and Safety Arrangements, issued as individual, topic-specific documents, in the form of Local Rules and Guidance documents. Level 3 Departmental Occupational Health and Safety Arrangements, prepared and issued by individual departments and reflective of the detailed Occupational Health and Safety Arrangements. These inform staff of relevant health and safety issues, together with the systems and procedures in place at departmental level to implement OHS Policy objectives. The University s Occupational Health and Safety Policy Statement commits it to ensuring, so far as is reasonably practicable, the occupational health, safety and welfare of all its staff members and those affected by its undertaking, including students, visitors, contractors and members of the public. Each department is required to embrace the objectives of the OHS Policy and to implement its associated arrangements to ensure the objectives are fulfilled. A fundamental principle underpinning health and safety law is that those who create risks from work activities are responsible for protecting workers and the public from the consequences. A similar principle is adopted by University Court. It accepts that in the course of a department s work or research risks to health and safety may be created. However, the nature of their undertakings does not exempt departments from statutory duties, therefore, they are expected to manage the risks they create. 1.2 Occupational Health and Safety Management System The University has adopted the Occupational Health and Safety Management System advocated by the Health and Safety Executive publication Successful Health & Safety Management (HSG65). This provides a robust framework to enable the University community, at both corporate and departmental level, to promote a positive occupational health and safety culture and to effect continual improvement. The components of the University s system are summarised below. OHS Policy This expresses a clear statement of commitment for managing occupational health and safety and specific objectives. It creates a framework for accountability that is led and adopted by senior management that will contribute to the delivery and success of the University s Strategy. Organising The organisational structure for managing occupational health and safety is clearly defined in the OHS Policy. Responsibilities are clearly allocated and employees at all levels are involved. The arrangements for communicating information and ensuring competence, training and consultation are also clearly presented. 3

4 Planning and Implementing This involves designing, developing and installing suitable proactive management arrangements, workplace precautions and their associated risk control systems, to protect the University community and to promote continual improvement. By implementing the detailed occupational health and safety arrangements, outlined in Level 2 of the OHS Policy, risks to safety, health and business continuity can be identified and either eliminated or controlled. Measuring Performance Measuring health and safety performance provides information upon which to judge the implementation and effectiveness of the arrangements for controlling risk. Information is gathered by both active and reactive monitoring systems, at departmental, Faculty and University levels. Information from active systems includes, reports of regular safety inspections for premises and equipment, the results of health surveillance, minutes of safety committee meetings, reports of training needs and the significant findings of risk assessments. Information from reactive systems includes, reports of accidents, damage to property or near-misses, analysis of accident trends and reports on weaknesses in performance standards. Reviewing Performance Periodic review considers the performance of the system as a whole, plus that of individual elements, to ensure its continuing suitability, adequacy and effectiveness. Departments and the University systematically review performance following events, such as incidents, accidents, ill-health, changes in activities or organisational structure, in order to consider improvements to management systems. Audit The University occupational health and safety audit programme will provide an independent, critical appraisal of the effectiveness of all elements of a department s occupational health and safety management arrangements. The outcome will be reported directly to the relevant Head of Department, the Chief Operating Officer, the University Occupational Health and Safety Consultative Committee and to the Audit Committee. Information link Control link Health & Safety Policy Establishes clear direction and demonstrates commitment to continual improvement Health & Safety Organisation Establishes responsibilities, relationships and good practices for carrying out Policy objectives Auditing Planning & Implementing Development and operation of management systems to prevent, eliminate and control hazards and risks Measuring Performance Process of gathering information on the effectiveness of the health and safety management system Reviewing Performance Making judgements and decisions about deficiencies or changes needed, based on performance measurements 4

5 1.3 Aim and Scope One of the key duties of Heads of Departments is to ensure that adequate departmental occupational health and safety arrangements are established and maintained to provide effective implementation of the Policy requirements. These arrangements constitute Level 3 of the Policy documentation structure. This Local Rule applies to all departments and its aim is to describe how University Court expects the above key duty to be fulfilled. It is designed to be a resource for Heads of Departments and focuses on key processes involved in developing and implementing effective health and safety arrangements. It includes a model for allocating key health and safety roles, together with a model for the content of departmental health and safety arrangements (Appendices 1 & 2 of separate document Appendices to Local Rule: Departmental Occupational Health and Safety Management Arrangements). 1.4 Terminology In terms of the OHS Policy, arrangements for managing occupational health and safety are defined as the systems and procedures that the University as a whole, and individual departments, are required to establish and maintain for ensuring the health, safety and welfare of staff and others who could be affected by its undertaking. 2. Key Role of Heads of Departments The Head of Department has a strategic and operational responsibility for health and safety management within their areas. Duties from Level 1 of the OHS Policy include: ensuring visible leadership in occupational health and safety management, being actively involved in the continual improvement of performance and able to demonstrate how this duty is achieved; ensuring suitable departmental occupational health and safety structures and arrangements are established and maintained to provide effective implementation of the OHS Policy, in line with the University s Occupational Health and Safety Management Arrangements and Local Rule: Departmental Occupational Health and Safety Management Arrangements; ensuring suitable written departmental safety arrangements are in place, communicated to all staff, signed, dated and reviewed annually; ensuring management arrangements for staff performance recognise the occupational health and safety duties as assigned by position or role; attending any specific health and safety training provided for Heads of Departments; ensuring the OHS Policy is brought to the attention of all new members of staff and that they are reminded of their responsibilities at regular intervals; 3. Organising for Effective Management 3.1 Understanding the Department s Undertaking Heads of Departments are required to have an appreciation of the extent of their departmental responsibilities, in terms of the space occupied, the facilities and services used and the nature of work/research activities, whether on- or off-campus, in order to establish and maintain control of risk factors. 5

6 They should ensure that their area of responsibility is divided into smaller areas or sections, for the purposes of managing occupational health and safety. Those who undertake joint degrees, are distance learning students, volunteers or casual workers etc. should be allocated to one of these areas, so that health, safety and welfare provision can be made for all concerned. It should be noted that the Director of Estates Services is responsible for ensuring the suitable and sufficient risk assessment of the operation of the estate, which includes buildings, communal areas, teaching rooms, grounds and gardens and all activities associated with the construction, refurbishment and maintenance of such areas. 3.2 Understanding the Department s Hazard Profile Heads of Departments are required to ensure that the hazards associated with each section/area of their department s undertaking are identified under broad categories. For example, mechanical hazards from work equipment; electrical hazards; explosion hazards from compressed gases or other atmospheres; chemical hazards; health hazards arising from the production of dusts or fumes; fire hazards; office hazards from trailing cables or layout of furniture, etc. This process will also help determine the allocation of health and safety responsibilities and whether any specialist training or advice is required. 3.3 Allocating Health and Safety Functions Each department needs an effective management structure for delivering Policy objectives and implementing arrangements. This can be achieved by pooling the knowledge and experience within a department and promoting co-operation between individuals and groups, so that health and safety becomes everyone s business. As a minimum, each Head of Department should appoint the following: a Departmental Safety Convener (DSC), a Deputy DSC, a Departmental Fire Safety Co-ordinator (DFSC), a DSE Assessor (all to be notified in writing to Safety Services on appointment or change of named individual) and a Departmental Safety Committee. Heads of Departments should allocate other key health and safety responsibilities and functions to line-mangers, individuals or groups, based on their job descriptions, areas/sections of control, the size of the department and its hazard profile, or in view of proposed changes to this profile. All functions, duties and accountabilities should be clearly defined and individuals given the appropriate level of authority to carry out their health and safety duties. Appendix 2 provides brief details of a range of suggested roles that may need to be fulfilled within many departments, especially by those in the Faculties of Science and Engineering. It includes the general function of each role, training and/or competence requirements and main duties. For the purposes of this document, the roles have been given distinct titles; however, in practice it is likely that a group of staff will each undertake one or more of the roles. Heads of Departments are at liberty to use Appendix 2 as a template and to customise it to suit the needs of their departments. Since the role of the DSC is to advise their Head of Department on health and safety matters and to co-ordinate arrangements, it is important that there is a direct reporting line to the Head of Department and it is advised that regular meetings are scheduled. 6

7 3.4 Ensuring Competence and Supervision Competence of Staff and Postgraduates As every individual has a part to play in maintaining health and safety standards, it should be ensured that each has the necessary awareness of University and departmental hazards, risks, procedures and arrangements etc., plus competency in applying knowledge and skills to enable them to carry out their work in a safe manner. A thorough health and safety induction programme is key to ensuring that new personnel (including postgraduate experimental research students and KTP Associates) receive appropriate awareness training. The programme should include a personal schedule of competency training, based on work activities and responsibilities. (See Departmental Health and Safety Induction for New Personnel - Checklist for Departmental Safety Convenors and Managers). Those with specific health and safety roles, should also receive the necessary training that will focus on both awareness and competency requirements, commensurate with their functions and based on an analysis of needs. Linemanagers should provide adequate supervision and discuss additional health and safety training and/or development needs during regular meetings with staff and at Annual Reviews. A list of training provided or arranged by Safety Services is given on their web pages. Where this does not meet all training needs, Safety Services may provide additional training or can advise on sourcing alternative providers. It should be ensured that all records associated with health and safety training should be retained within the department for at least 40 years. (See Personal Record of Health and Safety Training (S17)). It should be noted that in higher risk departments, DSC s will require to hold, or work towards, the NEBOSH National General Certificate in Occupational Health and Safety, or equivalent. The same applies where a departmental post includes the function of a DSC. In all other departments DSC s must complete the Institute of Occupational Safety and Health course Managing Safely. Appendix 2 may be revised to reflect this need Supervision of Undergraduates and Postgraduates The University has a duty to provide such information, instruction, training and supervision as is necessary to ensure the health, safety and welfare of students whilst undertaking coursework, which will include practical classes, project work, fieldwork, use of workshops outside normal hours, etc. It is the responsibility of each Head of Department to ensure that adequate arrangements are made, in all cases, to provide appropriate health and safety induction to students, including subsequent supervision. The Head of Department must also ensure that individual Academic Supervisors, Principle Investigators, tutors, line-managers, laboratory supervisors and demonstrators etc., have a clear understanding of their supervisory roles and are actively fulfilling them. Those in charge of particular aspects of coursework should decide on the extent of the supervision required, in each circumstance, based on a risk assessment undertaken by themselves, or other competent person. With regard to the health and safety supervision of postgraduate work, the member of academic staff responsible should regularly satisfy themselves that each stage of the research is based on a suitable and sufficient risk assessment, undertaken by a competent person, before it proceeds. 7

8 3.5 Ensuring Communication Heads of Departments should develop procedures for effectively communicating information concerning the Policy, departmental roles and responsibilities, as well as arrangements and/or their revisions etc. to those involved or affected. This may be achieved, for example, through occupational health and safety inductions, team/section briefings, agenda items, newsletters, s, management reports, notice boards, findings of risk assessments, safe systems of work, safety inspection reports etc. 4. Planning and Implementing Arrangements 4.1 Implementing University-wide Arrangements As an employer, many aspects of the University s undertaking are subject to statutory health and safety duties. Consequently, Safety Services maintains a legal register of applicable legislation, which drives the University s provision for health and safety and prepared occupational health and safety arrangements for managing risks associated with University work activities, hazards and other issues that fall within applicable duties. These arrangements represent Level 2 of the Policy documentation and comprise individual documents identified as Local Rules or Guidance. Both types set out the standards of management required by the University that, if adhered to, allow departments to demonstrate their compliance with legal duties and/or good practice. They normally include roles and responsibilities of various individuals and groups, along with practical advice on managing the associated risks. Local Rules may either be legislation specific or subject specific and are individually approved by the University Court, so are binding on all departments. Guidance documents are usually subject-specific and are approved by SACSOH. Although not binding on departments, they still represent the standard against which departments will be audited. An outline of the main points of each Local Rule and Guidance document is given in Level 1 of the Policy documentation, mainly as information to third party stakeholders. Heads of Departments should therefore make provision to integrate these management standards into their department s undertaking. 4.2 Preparing Departmental Occupational Health and Safety Arrangements Heads of Departments are required to ensure the preparation of written departmental occupational health and safety arrangements. Their contents should clearly outline how the department is organised for managing health and safety, together with the systems and procedures in place for ensuring that general risks, associated with the department s hazard profile, are being controlled. They should also indicate how applicable University-wide arrangements are implemented in the department. To reduce the amount of original work needed by each department and to achieve a consistent University-wide approach, Safety Services has prepared a set of Model Departmental Occupational Health and Safety Arrangements, see Appendix 1. The Model has been written from the standpoint of a department providing staff with a basic awareness of a range of issues. It briefly outlines the systems and procedures that exist (or should exist, if relevant) within departments to manage the health and safety implications of each issue. The content under each subject heading outlines the following: key definitions, the associated hazards and risks, the groups of people who could be affected, the departmental arrangements in place to control the risks, training requirements, general safety measures to be adhered to and applicable legislation/documentation for more detailed information or further reading, if required. 8

9 Where the Model refers to management actions by departments, these have been based on applicable legislation, Approved Codes of Practice or general good practice. It should therefore be ensured that systems and procedures for fulfilling these actions are actually in place and can be maintained within the department before departmental arrangements are issued. It is strongly advised that Heads of Departments use the format of the Model as a template for their own arrangements and use the same text under each applicable subject heading. Where a subject is not covered or departmental arrangements are different to those mentioned, then the Model should be edited as required. 4.3 Developing a Programme of Risk Assessments & Safe Systems of Work Under current legislation it is a legal requirement for the University (and hence departments) to undertake a suitable and sufficient assessment (in practice, this will usually entail a series of assessments) of the risks to the health and safety of employees to which they are exposed whilst at work, and of the risks to other persons arising out of, or in connection with its undertaking. The purpose of risk assessment is to enable departments to determine if enough precautions have been taken to prevent harm to people, or if more are needed. Furthermore, it is a legal requirement to provide safe systems of work to ensure the health, safety and welfare of employees whilst at work. Both the written Universitywide and departmental arrangements partly contribute to compliance with this duty, since they will outline certain preventive and protective measures. Due to individual departments undertaking very specific work and research activities that will not be covered by general arrangements, separate arrangements will need to be written. These may be in the form of recorded significant findings of risk assessments (for lower risk activities), or safe systems of work (for higher risk activities) developed from the significant findings of relevant risk assessments. Therefore, Heads of Departments must ensure that an adequate programme of risk assessment and safe systems of work is implemented to cover the full range of the department s specific work and research activities. This may necessitate ensuring that sufficient staff members are trained in risk assessment techniques and that the process is integrated into their normal work. Those affected need to be provided with comprehensible and relevant information on the risks to their health and safety and the preventive and protective measures in place or precautions required. The systems and procedures that ensure the programme of risk assessments and safe systems of work is implemented, together with the significant findings of risk assessments and/or the associated safe systems of work, will form part of the documentation that supports the departmental arrangements. 5. Measuring Performance The primary purpose of measuring health and safety performance is for departmental management teams to judge the implementation and effectiveness of the arrangements for controlling risk. Measurement information can be used to identify areas where corrective action is necessary and to determine how well a positive health and safety culture is being developed among staff and students, all with a view to continual improvement. Various means of monitoring can be employed as outlined below: 9

10 5.1 Reports of Accidents, Dangerous Occurrences and Cases of Occupational Ill Health The findings of investigations into the causes of accidents, dangerous occurrences and cases of occupational ill health (hereafter referred to as incidents), within a department, are vital. They provide useful information on health and safety management arrangements that may have failed, along with recommendations to improve future performance. It is advised that Heads of Departments ensure they are kept informed of all incidents, they monitor the progress of necessary changes to prevent a similar incident and that relevant information is communicated to those who could be affected. 5.2 Safety Inspections Heads of Departments should ensure that at least two safety inspections are carried out in each calendar year, the first between January and May, and the second between September and December. These should be wide-ranging and thorough and cover all areas and work activities under the control of the Head of Department. Inspection teams should use the relevant checklists and reporting template available in the document Guidance on Safety Inspections. 5.3 Annual Health and Safety Report Each Head of Department is required to complete an Annual Health & Safety Report and submit it to their Dean, or relevant senior officer, with a copy to Safety Services. This allows key health and safety indicators to be summarised and a judgement to be made about overall performance. It is recommended that Heads of Department base their comments for this report on at least two inspection reports, which will mean co-ordinating the timing of inspections and subsequent inspection reports, to allow their early January submission deadline to be achieved. 6. Reviewing Performance Reviewing is the process of using performance findings to make judgments about the adequacy of department s occupational health and safety management system and to take decisions about the nature and timing of actions to remedy deficiencies. Each Head of Department is therefore required to develop a Departmental Safety Action Plan (Safety Action Plan) to present and prioritise the longer term health and safety objectives of the department, with a view to continuously improving the health and safety management system and using limited resources efficiently. The Safety Action Plan may include risk-reducing actions identified by risk assessments or safety inspections, or items highlighted from the Annual Health and Safety Report, which require considerable planning, lead-time and financial resources. The abovementioned guidance provides further details of this plan. 7. References and further reading: Successful Health and Safety Management (HSG65) HSE Occupational health and safety management systems Requirements OHSAS

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